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Home , Pica (disorder)

: What is it and what can you do to help?

Authors: Chelsie Crowhurst, Therapies Assistant and Harpriya Baden, Assistant Psychologist at Options Malvern View and Options Bredon House

Introduction Why do people have Pica? It is not unusual for somebody on the spectrum Listed below are some of the known reasons that people to have additional diagnoses related to other conditions. engage in Pica. One such example of this is Pica. A review by Matson and his colleagues (2013) reports the prevalence of Pica to be Medical Reasons between 4 and 26%, however there are significant numbers • of cases that are not reported and so it is likely that the • Zinc deficiency actual prevalence of Pica is higher. • Anaemia This help sheet aims to provide you with information about • Relieve pain and discomfort Pica; what it is, why some people with autism have a • Reduce anxiety or diagnosis of Pica, the risks associated with Pica, and outlines some of the support strategies that can be used. Dietary Explanations

• To lose weight (non-nutritional items eaten to feel full) What is Pica? Pica is a serious , which can be life threatening Sensory Function if left unmanaged. Pica refers to eating or mouthing inedible and inappropriate items such as; clothing, faeces, dirt, metal • Enjoy texture or taste of the item and stones. Behavioural Purpose • Seeking attention Pica is much more common in those with developmental and behavioural disorders, in particular autism compared to • Avoiding a task the general population. The prevalence of Pica in autism is • Continuing an infant mouthing behaviour estimated to be between 0.3% - 25.8% (Ali, 2001; Ashworth • Relieving stress or anxiety et al., 2009). • Not understanding the difference between edible and inedible items

optionsautism @optionsautism What are the signs and symptoms? How do we assess the level of risk associated Many people with developmental disabilities and/or autism with Pica? may explore items orally, so how do you know whether they A diagnosis of Pica suggests that there are additional risks that are engaging in Pica? Families and carers should be vigilant need to be considered. The risk of ingesting harmful substances for any of the following signs and symptoms. If any of these and the consequences associated with that are significantly are identified or observed, you should seek medical support. increased. • witnessing them eat a food that is not edible such as stones or metal The information below describes a way of assessing the level of risk associated with Pica proposed by Sturmey and Williams • upset and/or pain (2016): • Blood in stool • Bowel problems (constipation or diarrhoea) Level of Risk: Undetermined Definition:This is when there could be a diagnosis of Pica if Other serious symptoms of Pica occur as a result of ingesting the individual would continue to ingest non-food items however toxic and poisonous items such as: there is no current danger currently. • Household cleaning products • Toxic plants in the garden Level of Risk: Serious • Animal poisons left around the house or garden Definition:The individual has passed a foreign object, such as stones, in their stool, spitting it out or even on the There can be more serious symptoms which occur as a result object one time. of eating something toxic or poisonous and the bacteria from these non-food items, such as: • Intestinal blockage Level of Risk: Dangerous • Injuries to teeth Definition:There has been more than one episode of passing • Infections foreign objects through stool, spiting it out or choking. • poisoning (Paint chips containing lead) Level of Risk: Highly Dangerous Any evidence that the person you support is ingesting non- food items should be discussed with their GP. Definition:This would include having more than one episode of passing foreign objects AND needing surgery due to ingesting foreign objects on one occasion. How is Pica diagnosed? Pica can only be formally diagnosed by a doctor. If you notice any behaviours related to Pica it is important to keep Level of Risk: Life-Threatening a diary of; the types of items that are being consumed, Definition: If the individual has needed more than one surgery quantity, and times the behaviour occurs. This information is due to ingesting foreign objects. important to understand patterns of behaviour and the risk associated. What can you do to help? In the UK, the ICD-11 is used to guide practitioners on The environment plays an important role in reducing the diagnosing Pica. The ICD-11 characterises Pica as “the regular risks associated with Pica and should be considered alongside consumption of non-nutritive substances, such as non- individual strategies. food objects and materials (e.g., clay, soil, chalk, plaster, plastic, metal and paper) or raw food ingredients (e.g., Environmental Strategies large quantities of salt or corn flour) that is persistent or severe enough to require clinical attention in an individual When considering environmental strategies it is important who has reached a developmental age at which they not to restrict the person’s environment but instead carry out would be expected to distinguish between edible and non- an assessment of the environment to highlight areas of risk. edible substances (approximately 2 years). The behaviour In order to provide a safer environment the below check list causes damage to health, impairment in functioning, or adapted from Sturmey and Williams (2016) can help families and significant risk due to the frequency, amount or nature of the carers to manage environmental risks. substances or objects ingested.” (World Health Organization, 2018). Questions - Yes or No 1. Is the floor clear of items? It is possible your doctor may conduct further tests such as a blood test to rule out other possibilities such as anaemia, iron 2. Do any toys/games/activities have loose pieces? or zinc deficiency. 3. Do any toys/games/activities have small pieces that ingestion could happen? Ensure that they are seen by a doctor when these 4. Are pens, paper, paper clips within reach or behaviours start for an accurate diagnosis and also to avoid unattended? misdiagnosing. This is also important if the individual begins to display any more signs and symptoms or they get worse 5. Are there any cupboards or closets that are unlocked? as they could have caused damage internally or have a 6. Is there a rubbish bin? coexisting deficiency like anaemia.

optionsautism @optionsautism ©Options 2019 | Autism Information Sheet | Issue 27 7. Are you always present? • Hagopian, L. P., González, M. L., Rivet, T. T., Triggs, 8. Any torn clothing? M., & Clark, S. B. (2011a). Response interruption and differential of alternative behavior for 9. Are any cleaning items within reach? the treatment of Pica. Behavioral Interventions, 26(4), 10. Any other items in reach? 309-325. Areas on the checklist identified as ‘yes’ pose a possible • Hagopian, L. P., Rooker, G. W., & Rolider, N. U. risk for those known to engage in Pica. It’s therefore (2011b). Identifying empirically supported treatments important to minimise the risks that have been identified. for Pica in individuals with intellectual disabilities. For example; if there’s a rubbish bin, choose one with Research in developmental disabilities, 32(6), 2114- a closed lid not an open waste basket as the individual 2120. cannot see what is inside and are less likely to engage • Matson, J. L., & Bamburg, J. W. (1999). A descriptive in Pica behaviour. A study by Schmidt et al. (2017) study of Pica behavior in persons with mental found that when inedible objects are removed from the retardation. Journal of Developmental and Physical environment, then the individual can be supported to find Disabilities, 11(4), 353-361. more appropriate, alternative behaviours. • Matson, J. L., Hattier, M. A., Belva, B., & Matson, Individual Strategies M. L. (2013). Pica in persons with developmental disabilities: Approaches to treatment. Research in There are also a number of individual strategies that can developmental disabilities, 34(9), 2564-2571. be used to support those engaging in Pica. • McAdam, D. B., Sherman, J. A., Sheldon, J. B., & Firstly, individuals can complete a sorting activity where Napolitano, D. A. (2004). Behavioral interventions they identify edible and inedible items, this can be aided to reduce the Pica of persons with developmental through using PECS (Picture Exchange Communication disabilities. Behavior modification, 28(1), 45-72. System). Through educating individuals about items they can differentiate between inedible and edible items. • Schmidt, J. D., Long, A., Goetzel, A. L., Tung, C., Pizarro, E., Phillips, C., & Hausman, N. (2017). Other techniques used to keep those engaging in Pica Decreasing Pica attempts by manipulating the safe involve replacing the inedible items with edible items environment to support prosocial behavior. Journal of a similar texture, smell and taste. of Developmental and Physical Disabilities, 29(5), 683-697. Generic techniques that could minimise Pica related behaviours include engaging the person in structured • Stiegler, L. N. (2005). Understanding Pica behavior: A enjoyable activities in order to redirect focus from the review for clinical and education professionals. Focus consumption of inappropriate items. on Autism and Other Developmental Disabilities, 20(1), 27-38. Where can you seek additional help? • Sturmey, P., & Williams, D, E. (2016). Pica in Individuals with Developmental Disabilities. If you have any concerns about the person you support Switzerland: Springer International Publishing. then it is important to seek additional help, primarily through your GP. If you have access to other professionals • World Health Organization. (2018). International such as a dysphagia trained speech and language classification of diseases for mortality and morbidity therapist, occupational therapist or clinical psychologist, statistics (11th Revision). Retrieved from https://icd. then you can always seek advice from them too. who.int/browse11/l-m/en

It is important to seek help from a healthcare professional in order to formally assess the behaviour of concern and to gain access to appropriate support.

References Spread the word... • Ali, Z. (2001). Pica in people with intellectual If you found this help sheet useful please feel free to share disability: A literature review of aetiology, it with anyone who you feel may benefit. epidemiology and complications. Journal of Intellectual and , 26(3), 205- Our help sheets are produced monthly and written by our 215. clinical team. If you would like us to cover any particular subjects around autism in future editions then • Ashworth, M., Hirdes, J. P., & Martin, L. (2009). The please let us know by emailing [email protected] social and recreational characteristics of adults with and Pica living in institutions. The complete series of help sheets can be found on our Research in developmental disabilities, 30(3), 512- website www.optionsautism.co.uk/resources 520.

For further information about our schools and homes throughout England and Wales for children and adults with autism, complex needs and learning disabilities call: 08442 487187 | email: [email protected] | website: www.optionsautism.co.uk 7 optionsautism @optionsautism ©Options 2019 | Autism Information Sheet | Issue 27